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Chapter 30 Coordinating Care for Patients With Cardiac Disorders
medications require careful monitoring of blood pressure, heart rate, and cardiac rhythm and frequent assessments to guide therapy and avoid adverse effects.
quality of life. Critical interventions by the healthcare team include teaching related to medications, sodium restriction, and weight management; symptom monitoring; screen- ing for depression and mental health comorbidities; evalu- ating social support structures; planning and encouraging participation in cardiac rehabilitation; and implementing behavior-change strategies, such as motivational interview- ing (see Evidence-Based Practice). Intensive intervention programs can combine in-patient interventions with home care and follow-up contacts. Self-management is affected by the patient perceptions of interactions with healthcare team members. Improved self-management occurs when patients perceive that their healthcare team members are responsive, interested in their individual needs, and share information. Poor communication and lack of continuity can be barriers to self-management.
Safety Alert
Care Considerations When Giving IV Furosemide and Morphine Together
Both medications can cause hypotension. BP should be monitored frequently, as should level of consciousness (LOC). Potassium levels should also be monitored because furosemide can cause hypokalemia. Urine output should be assessed. Fall precautions are needed due to the potential for hypotension and CNS depression, as well as the need to frequently void. Frequent respiratory and LOC assessments should be done as morphine can cause respiratory and CNS depression. Device and Surgical Intervention As HF progresses, more invasive treatments are needed to support cardiac function and control the complications that result. Implantation of an automatic internal cardiac defibrillator (ICD) and a pacemaker may be considered for dysrhythmia control and ventricular resynchroniza- tion, also referred to as cardiac resynchronization therapy (CRT). Continuous IV inotrope therapy, an intra-aortic balloon pump, and other mechanical circulatory support (MCS) devices such as a ventricular assist device (VAD) can be used to support the failing heart. Depending on the cause of HF, valve replacement or heart transplanta- tion may be considered. In addition to treatment, symp- tom management to improve healthcare-related quality of life (HRQOL) should always be considered. Palliative care is often indicated for patients with end-stage HF (NYHA class IV or AHA/ACC stage D). Self-Management Self-management is a critical component of HF treatment. Patients must assume responsibilities for symptom moni- toring, medication adherence, and lifestyle changes. Daily weights taken at about the same time each day monitor fluid retention. Weight gain indicates fluid retention. A gain of 1 kg is the equivalent of 1,000 mL of fluid retention. A gain of more than 1 kg (2 lb) in a day or 2 kg (5 lb) in a week may be significant. Lifestyle changes typically include a sodium-restricted diet, maintaining optimal weight, and preventing cardiac cachexia. Sodium restriction to 1,500 mg/day is recommended in the early stages of HF, with a less restrictive recommendation of up to 4,000 mg/ day in later stages. A high BMI is associated with a higher mortality and, although a lower BMI is generally posi- tive, weight loss in a patient with HF may reflect cardiac cachexia, which may also contribute to higher mortality. Management interventions by the interprofessional healthcare team may have a beneficial effect on self- management and thus on HF-related hospitalization and
Evidence-Based Practice
Cardiac Rehabilitation for Heart Failure Persons with HF experience reduced capacity for phys- ical activity, which can have detrimental effects on their quality of life and contribute to hospitalizations and mortality. In a 2019 Cochrane Review of evidence, researchers found a reduced risk of overall hospital admissions in the short term when patients are enrolled in cardiac rehabilitation. In a meta-analysis of 18 clinical trials, another group of researchers found that participa- tion in exercise programs improved short- and long-term left ventricular function. An expert panel from the Amer- ican College of Cardiology reviewed available evidence and recommends cardiac rehabilitation as a safe and effective strategy to improve quality of life, functional capacity, exercise performance, and decrease HF-related hospitalizations. Despite evidence from this study and many others, as well as reimbursement by the Centers for Medicare and Medicaid Services, referral to and attendance in such programs remain low. More patients with HF need to be referred to and encouraged to partic- ipate in cardiac rehabilitation. Bozkurt, B., Fonarow, G., Goldberg, L., Guglin, M., Josephson, R., Forman, D., ... Wolfel, E. (2021). Cardiac rehabilitation for patients with heart failure: JACC Expert Panel. Journal of the American College Cardiol- ogy, 77 (11), 1454–1469. doi: 10.1016/j.jacc.2021.01.030. PMID: 33736829. Fukuta, H., Goto, T., Wakami, K., Kamiya, T., & Ohte, N. (2019). Effects of exercise training on cardiac function, exercise capacity, and quality of life in heart failure with preserved ejection fraction: A meta-analysis of randomized controlled trials. Heart Failure Review, 24, 535–547. https:// doi.org/10.1007/s10741-019-09774-5 Long, L., Mordi, I., Bridges, C., Sagar, V., Davies. E., Coats, A., Dalal, H., Rees, K., Singh, S., & Taylor, R. (2019). Exercise-based cardiac rehabilitation for adults with heart failure. Cochrane Database of Systematic Reviews 1(1):CD003331. https://doi.org/10.1002/14651858. CD003331.pub5
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